This research asks whether a cervical cancer prevention programme in South Africa that includes an HPV vaccine is more cost-effective than the current strategy of screening alone. It found that, while a combination of vaccination and screening at the current vaccine price is more costly than screening alone, it is a cost-effective strategy for preventing cervical cancer. The main cost driver is the vaccine cost. If the vaccine price is reduced, vaccination followed by screening might be a very affordable policy option. The vaccine has the potential to reduce the incidence of HPV-related diseases, and to reduce the cost of treating cervical cancer. This requires a well-functioning screening programme aimed at secondary prevention of cervical cancer as the HPV vaccine does not eliminate, but rather reduces the risk of cervical cancer. In South Africa, screening coverage is very low (well below 50%) and adherence to treatment of pre-cancerous and cancerous lesions is also less than 100%, thus having another preventative measure could be desirable. Approaches for reducing the cost of introducing the vaccine (which should be publicly funded) include accessing international funding mechanisms, such as the United Nations Children’s Fund (UNICEF), using public-private partnerships and getting commitment from pharmaceutical companies to reduce prices.
Equitable health services
Microbicides Development Programme 301 was a phase 3, randomised, double-blind, parallel-group trial, undertaken at thirteen clinics in South Africa, Tanzania, Uganda, and Zambia. The study enrolled 9,385 of the initial 15,818 women who were screened. Mean reported gel use at last sex act was 89%. HIV-1 incidence was much the same between groups at study end, for placebo, for hazard ratio 1.05, and at discontinuation. Incidence of the primary safety endpoint at study end was 4.6 per 100 woman-years in the 0.5% PRO2000 group and 3.9 in the placebo group; and was 4.5 in the 2% PRO2000 group at discontinuation. The study concludes that, although they are safe, 0.5% PRO2000 and 2% PRO2000 gels are not efficacious against vaginal HIV-1 transmission and are not indicated for this use.
An estimated 55,000 people die of rabies in Africa and Asia every year, a viral disease passed from an infected animal to a human through biting or scratching. In both humans and animals it is deemed fatal once it enters the central nervous system, with only a handful of survivors. Already nine human cases that resulted in death have been confirmed in South Africa this year; three in the Eastern Cape, two in Kwa Zulu-Natal, one in Mpumalanga and three in Limpopo. Experts in the medical fraternity have described this as worrying, saying people need to be aware of rabies. Professor Lucille Blumberg of the National Institute for Communicable Diseases, says her institution deals with up to 20 cases of human rabies per year. She says that if a person is bitten by a stray animal, they should immediately wash the wound very well, to physically remove the virus, then visit a clinic immediately to get an injection to prevent infection and to go on a course of injections to develop antibodies to the disease.
The Global Plan to Stop TB 2011-2015 is a new roadmap for curbing the global epidemic of tuberculosis, and it aims to save five million lives between 2011 and 2015 and eliminate TB as a public health problem by 2050 but comes with a price tag of US$47 billion, nearly half of which must still be found. The Plan builds on progress towards goals laid out in 2006 to halve TB prevalence and death rates by 2015 and scale up TB diagnosis, treatment and care, but adds essential research targets including the development of faster methods to test and treat TB and to prevent it through an effective vaccine. Specifically, the plan provides countries with guidance on how to improve TB control through scaling up existing interventions for its diagnosis and treatment and by making use of new diagnostic tests and drugs that will become available over the next five years. A new test that uses molecular line probe assays to detect multi-drug resistant (MDR) TB in a few days instead of the weeks needed using older testing methods has already been introduced in some countries. Other tests that will soon be available can detect TB in a matter of hours. The pipeline of new TB drugs promises shorter treatment times. Meanwhile, nine TB vaccine candidates are in clinical trials and a new generation of TB vaccines is expected to be available by 2020. Other major elements of the plan focus on efforts to combat drug-resistant TB and TB in people living with HIV. It calls for a scale-up in access to tests that can detect resistance to first- and second-line TB drugs, identifying limited laboratory capacity as the main reason why only 5% of the estimated 440,000 people who had MDR-TB in 2008 were diagnosed. It also recommends testing all TB patients for HIV and providing antiretroviral treatment to all those who test positive.
The study’s aim was to estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion. In the study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, researchers reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009 to identify predictors for completion through multivariate logistic regression. Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART, only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks. The study concluded that patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. It recommends health information systems that link testing programmes with care and treatment programmes.
This report presents the global treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.
Severe overcrowding in KwaZulu-Natal’s prisons is contributing to the spread of HIV and tuberculosis and driving the high death toll in prisons, according to King Kumalo, provincial deputy director of health services in the Department of Correctional Services (DCS), in his address to the annual meeting of Hospice Palliative Care Association on 1 September 2010. So far this year, 120 prisoners have died of ‘natural causes’ (diseases) and eight of unnatural causes in KwaZulu-Natal, he reported. In the past, there were more unnatural deaths such as murder and suicide than natural deaths, said King. Last year, 168 prisoners died of natural causes while 14 died of natural causes. As a result of the high death toll, the DCS has brought in hospice workers to assist them to treat people with advanced disease who are in need of pain relief. The HPCA, cares for over 70,000 patients at 200 sites countrywide, also has a memorandum of understanding with the SA National Defence Force to provide palliative care (pain relief). However, hospice workers reported that HIV and TB – particularly drug-resistant TB - were challenging their resources. A shortage of beds for patients, long travelling distances to treatment centres were cited as obstacles, while many of the local clinics were reported to not offer monthly tests on people with drug-resistant TB because staff are scared of becoming infected.
This study took the form of a process evaluation of the tenfold scale-up of an evaluated Youth Friendly Service (YFS) intervention in Mwanza Region, Tanzania to identify key facilitating and inhibitory factors from both user and provider perspectives. The intervention was scaled up in two training rounds lasting six and ten months and evaluated through a simulated patient study, focus group discussions and semi-structured interviews with health workers and trainers, training observations and pre- and post-training questionnaires. The study found that, between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time trainers' confidence and ability to lead sessions improved. The scale-up faced challenges in the selection and retention of trained health workers, however, and was limited by various contextual factors and structural constraints. The study concludes that YFS interventions can remain well delivered even after expansion through existing systems. The scaling up process did affect some aspects of intervention quality and the findings emphasise the need to train more staff (both clinical and non-clinical) per facility in order to ensure YFS delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale-up.
This paper presents the results of a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics. Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Provider and patient interviews at both of the sites in the study indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. The paper argues that integrating vertical anti-retroviral therapy and outpatient services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalisability.
The objective of this study was to assess the relationship between the prevalence of vitamin A deficiency among pregnant women and the effect of neonatal vitamin A supplementation on infant mortality. The study’s literature review revealed that studies of neonatal supplementation with vitamin A have yielded contradictory findings with regard to its effect on the risk of infant death, possibly owing to heterogeneity between studies. One source of that heterogeneity is the prevalence of vitamin A deficiency among pregnant women, which the study examined using meta-regression techniques on eligible individual and cluster-randomised trials. The meta-regression analysis revealed a statistically significant linear relationship between the prevalence of vitamin A deficiency in pregnant women and the observed effectiveness of vitamin A supplementation at birth. In regions where at least 22% of pregnant women have vitamin A deficiency, the study recommends giving neonates vitamin A supplements to help protect against infant death.